Failure to Integrate Hospice Plan of Care Into Resident’s Comprehensive Care Plan
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving hospice services had a comprehensive written plan of care that incorporated the hospice plan of care and clearly described the services the facility would provide. The resident was discharged from the hospital with diagnoses including repeated falls, Parkinson’s disease with dyskinesia, and dementia, with hospice care as the discharge disposition. A hospice initial coordination note documented goals related to pain management and visit frequencies for nursing and social work, and indicated hospice would deliver the initial hospice plan of care to the facility. However, these hospice goals and interventions were not integrated into the facility’s care plan, and the hospice plan of care was not provided to the surveyor upon request. The resident’s ADL care plan did not include the most recent hospice plan of care and lacked documentation of how the facility would coordinate or provide services to support hospice interventions. Record review for the month showed there was no comprehensive written plan of care that combined the hospice plan with facility services such as nursing interventions, ADL assistance, and pain monitoring. A NA reported knowing the resident was on hospice but not knowing the specifics of hospice care needs, including required pain monitoring frequency or comfort-focused ADL approaches, stating she had not been informed of hospice-specific interventions. An RN confirmed that the resident’s comprehensive care plan should have reflected individualized hospice goals and interventions but acknowledged she could not locate a comprehensive hospice care plan in the record. A hospice RN stated she did not provide the comprehensive hospice plan of care to the facility, focusing instead on medication management, and stated staff should have access to a hospice plan of care identifying needs and interventions. The DON stated the facility relied on hospice to manage their plan of care, was unaware whether the hospice plan had been integrated into the resident’s comprehensive care plan, and could not confirm whether hospice-related interventions such as pain, anxiety, shortness of breath management, and psychosocial support were present. The facility’s comprehensive care plan policy was requested but not provided, while the resident assessment policy required a comprehensive care plan for all admitted residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to maintain coordinated hospice care plans for two residents. One resident with dementia, ASHD, and PVD had a care plan that still referenced a prior hospice and lacked the current hospice provider, hospice visits, supplies, DME, and covered meds; the MDS also did not document hospice services. Another resident with HTN, MDD, and schizoaffective disorder had a hospice care plan that lacked visit frequency, supplies, meds, and DME details, and the hospice binder was incomplete. Staff interviews confirmed the missing hospice coordination information.
Failure to Document Hospice Collaboration in Care Plan: A resident with dementia, cognitive communication deficit, and myasthenia gravis was receiving hospice services, but the care plan did not include the frequency of hospice visits, the care hospice would provide, or the medications and equipment hospice would supply. Staff stated hospice-related information should be listed on the care plan, and the facility policy called for coordination of care with hospice staff.
A resident receiving hospice services had no IDG meeting notes in the hospice binder since hospice start of care. The hospice RN said the notes were never requested, while facility staff, including the DON and Administrator, were unaware of the required binder contents or lacked a system to ensure the binder was complete, despite using it for care coordination and order review.
A resident with cerebral infarction, DM, tracheostomy, dysphagia, and a G-tube was receiving hospice services, but the facility’s care plan did not include the frequency and type of hospice support visits, supplies, or medical equipment. The plan only addressed medication administration, pain monitoring, notification of hospice for condition changes, and DNR status, while staff stated the care plan should reflect care provided by both the facility and hospice.
Hospice care coordination and care plan deficiencies were identified for a resident with DM and COPD who was receiving hospice services. The RNCM did not know what hospice information belonged in the care plan or which staff were responsible for coordinating with hospice, and the DNS acknowledged there were no designated staff members identified to communicate with hospice representatives. The resident’s care plan also did not include hospice-related information, including the Hospice Plan of Care.
The facility failed to coordinate hospice care and keep hospice binders current for two residents receiving hospice services. One resident with dementia had a hospice binder missing recent IDG meeting documentation and an updated care plan, while another resident with stroke, anxiety, and depression did not have the most up-to-date hospice medication list. Interviews confirmed the hospice binder was expected to contain current orders, care plans, IDG notes, and medication information for continuity of care.
Missing Hospice Coordination and Care Plan Information
Penalty
Summary
The facility failed to ensure a coordinated plan of care was developed and available for two residents receiving hospice services. For one resident with dementia, arteriosclerotic heart disease, and peripheral vascular disease, the record showed hospice enrollment and a later change to a current hospice provider, but the care plan still referenced the previous hospice and did not identify the current hospice provider, the services hospice would provide, hospice staff visits, supplies, medical equipment, or medications covered by hospice. The resident’s MDS also lacked documentation that hospice services were being received, and the medical record did not show coordination of care between the facility and the current hospice provider. For another resident with HTN, major depressive disorder, and schizoaffective disorder, the record showed hospice services were in place and the resident had moderately impaired cognition with disorganized thinking and inattention. The care plan stated the resident was on hospice and included general comfort and ADL support measures, but it did not include how often hospice staff would visit, what supplies and medications hospice would provide, or what DME hospice would provide. The hospice provider binder also lacked a complete plan of care with required information, including the most recent recertification order and related details. During observations, one resident was seen in a Broda chair being assisted with lunch, and the other was seen in a Broda chair getting ready to receive noon medications. Staff interviews confirmed the missing hospice coordination information. An Administrative Nurse stated the facility should have a hospice care plan to coordinate with hospice services and acknowledged the current hospice information was not in the care plan. A CNA stated staff usually relied on the nurse to explain what hospice provided, and a nurse stated the hospice book should contain the information from the hospice POC and that the resident care plan should reflect the same information.
Failure to Document Hospice Collaboration in Care Plan
Penalty
Summary
The facility failed to ensure collaboration with the hospice provider for a resident with cognitive communication deficit, dementia, and myasthenia gravis. The resident’s EMR documented a diagnosis of myasthenia gravis, and the Quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition. The resident had received hospice services, and the care area assessment noted staff would assist with activities of daily living as needed and therapy would work to increase functional mobility. The resident’s care plan included interventions for pain, restlessness, agitation, constipation, and other symptoms of discomfort, along with instructions to notify hospice of significant changes, clinical complications, need for emergency transfer, or death. However, the plan did not include the frequency of hospice staff visits or the care they would provide, and it did not list the medications and equipment to be provided by hospice. Staff interviews indicated the hospice-related information should be included on the resident’s care plan, and the facility’s hospice coordination policy stated care would be coordinated with hospice staff to promote the resident’s highest practicable well-being.
Missing Hospice IDG Documentation and Care Coordination
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, including communication with the hospice medical director, the resident’s attending physician, and others involved in care. The resident was an elderly female admitted with a primary diagnosis of dementia and had an order to admit to hospice on 06/10/2026. A significant change MDS reflected severe cognitive impairment with a BIMS score of 03, and the care plan dated 06/16/2026 identified the need for hospice services with hospice staff assisting the facility in care for the resident. Record review of the resident’s hospice binder on 07/29/2026 showed there were no Interdisciplinary Group (IDG) meeting notes in the section designated for them since the start of hospice care. The hospice RN stated she had never been asked to bring IDG meeting notes to the facility and explained that the IDG meetings were used by providers to collaborate on the resident’s plan of care, orders, and goals. Facility staff, including RN B, Medical Records, the DON, and the Administrator, stated they were unaware of what documents were required in the hospice binder or did not have a system to ensure the binder was complete, although they acknowledged the binder was used for coordination of care and expected IDG meetings to be included.
Hospice Care Plan Lacked Coordination Details
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice for one resident who was receiving hospice services. The resident’s EMR documented diagnoses of cerebral infarction, DM, tracheostomy, and dysphagia. The Quarterly MDS documented that cognition was not assessed, the resident was dependent on staff for all ADLs, received tracheostomy care, had a G-tube, and received hospice services. The resident’s care plan dated 06/02/2026 included interventions to administer medications as ordered, monitor for verbal and nonverbal cues of pain, intervene accordingly, notify hospice of any changes in condition, and noted a DNR. However, the care plan lacked the frequency and type of support visits, supplies, and medical equipment provided by hospice. The resident was admitted to hospice on 09/06/2025, and the facility had a hospice plan of care in a communication book dated 06/04/2026. An Administrative Nurse stated she was new to the position and would update the care plan with the information required related to hospice care, and another Administrative Nurse stated the care plan should reflect the care provided by both staff and hospice. The facility’s Hospice Program policy stated that the facility should collaborate with hospice, the nursing home, and the resident/representative on a coordinated care plan in the medical record.
Hospice Care Coordination and Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure there was a designated staff member responsible for collaborating and communicating with hospice representatives, and the resident’s care plan did not include the hospice plan of care for 1 resident receiving hospice services. Resident 2 was admitted to the facility in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder. An Election of Benefits and Informed Consent document showed the resident was admitted to hospice services on 5/24/26. Review of the care plan showed it did not include hospice-related information, including a Hospice Plan of Care. During interviews, Staff 6, the RNCM, stated she did not know what information needed to be on the care plan for residents receiving hospice services and did not know which staff members were responsible for collaborating and coordinating with hospice representatives for Resident 2. Staff 6 acknowledged that Hospice Plan of Care information was not included in the resident’s care plan. Staff 2, the DNS, also acknowledged the facility did not have designated staff members identified to communicate and collaborate with hospice representatives for Resident 2 and that Hospice Plan of Care information was not included in the resident’s care plan.
Hospice Documentation and Care Coordination Lapses
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services, including communication with the hospice medical director, the attending physician, and others involved in care. For Resident #4, who was re-admitted with diagnoses including dementia, muscle weakness, anxiety, and depression, the quarterly MDS indicated severe cognitive impairment and that the resident was on hospice services. The care plan identified a terminal prognosis and hospice services, with interventions focused on comfort and adjusting ADLs to the resident’s changing abilities. Record review of Resident #4’s hospice binder showed that it did not contain the last two IDG meetings or an updated care plan. The hospice RN stated the binder should contain supporting documentation such as the face sheet, election form, code status, certification of terminal illness, plan of care, and medications, and that documentation should be updated after IDG meetings. She reviewed the binder and noted the last IDG meeting in the binder was from 06/18/26 and the last care plan was from 02/22/26, while an IDG meeting from 07/02/26 was not in the binder. She stated she did not know why the updated care plan or IDG meeting was missing. For Resident #3, who was re-admitted with diagnoses including stroke, anxiety, and depression, the quarterly MDS showed severe impairment in cognitive skills for daily decision making and that the resident was receiving hospice services. The care plan indicated hospice services for stroke and cooperation with the hospice team to meet the resident’s needs. Record review showed a physician order for sertraline and a hospice medication list printed on 06/29/26 that listed sertraline 50 mg daily for depression, but the facility failed to obtain the resident’s most up to date hospice medication list. Interviews with the hospice nurse, LVN, DON, and administrator confirmed that the hospice binder was expected to contain current hospice documents and that updated information was to be provided by hospice for continuity of care.
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